April 5, 2002

By Nancy Volkers
InteliHealth News Service

They say too much of anything can kill you, but some people are finding that a little bit of poison can actually make them look young again.

Botulinum toxin A, one of several poisons produced by the bacteria Clostridium botulinum, is said to be close to approval by the U.S. Food and Drug Administration for cosmetic purposes.

Clostridium botulinum also causes botulism, a rare and often fatal infection that causes muscle paralysis.

Botulinum toxin A, which goes by the trade name Botox, is already approved for cervical dystonia (neck pain) and two associated conditions: eyelid spasms (blepharospasm) and misalignment of the eyes (strabismus). In the United States, it's also being used off-label (without FDA approval) for trigger-point muscle injections and hyperhidrosis (excessive perspiration), among other conditions.

Botox disrupts the communication between nerves and muscles. "[Our nerve endings] stop short and produce a chemical, acetylcholine, that activates the muscle," says Harold DeMonaco, director of drug-therapy management at Massachusetts General Hospital. "Botox blocks the release of acetylcholine; it unplugs the muscle from the nervous system."

In fatal cases of botulism, the toxins are spread through the bloodstream, paralyzing many muscles, including those used for breathing. When used for cosmetic purposes, very small doses of Botox, injected just under the skin, paralyze specific muscles of the face.

The effect wears off after three or four months, depending on how much toxin is used and which muscles have been injected. So far, insurers aren't covering the injections, which cost from $300 on up.

Still, even before FDA approval for cosmetic use, thousands of people are getting Botox injections for forehead wrinkles, smile lines and crow's feet. Bonnie Schulman, a physical therapist from Baltimore, Md., has had three rounds of injections in her forehead.

"I have always had eye issues — I've been nearsighted since the age of 8, wearing glasses, squinting … I have a lot of tension in my forehead," says Schulman, who is in her mid-50s.

She was spurred to action by her daughter's wedding, scheduled for October 2001. In July of that year, Schulman visited a plastic surgeon for a "trial run." "I wanted to have time to do another one if I liked it, and if I didn't, I wanted time for it to wear off," she says.

The results? "It was great! It helps with headaches because I can't squint — the muscle is frozen," Schulman says. She thinks her forehead lines look less noticeable, and says people have told her that she looks more relaxed.

Visiting a plastic surgeon or a dermatologist for these injections is important, says DeMonaco. "When Botox is in the right hands, there seem to be no side effects," he says. "But people need to understand that this is a toxin. Knowing where to inject and how much to inject is very important."

In less experienced hands, the wrong muscle could be injected, resulting in drooping of an eyelid or a facial muscle. In a worst-case scenario, the toxin — normally injected under your skin — could enter your bloodstream. (The doses used cosmetically, however, are only a small fraction of the dose necessary to induce botulism.)

And don't forget, these are injections — you can expect to receive between three and six for crow's feet, and as many as 15 for forehead wrinkles — so there is some pain.

"It does hurt when you get it done, and you walk around looking like you have chickenpox for about an hour," Schulman says. "But that goes away fast … It's uncomfortable, but as with any cosmetic process, we don't care!"

Because the treatment isn't permanent, there can be some long-term consequences. "You can develop antibodies to Botox, and many people do with repeated injections," DeMonaco says. "That makes it work less well."

Also, he says, the body may try to compensate for the disconnection between the nerves and the muscle by growing more nerve endings to that muscle. That means future injections at the same concentration of toxin may be less effective because there are more nerves to block, and you may need higher doses.

"On a theoretical basis, the risk is that when you stop using it you end up with deeper wrinkles than when you started because you have more muscle-nerve connections," DeMonaco says.

Schulman says that now that she's tried it and liked it, she'll probably keep doing it. "It's not cheap; it's a luxury. But in the scheme of things, it's not that major if you're looking at plastic surgery as an alternative … I think it's a remarkable thing to be able to do."

If you agree, DeMonaco suggests sitting down and thinking about it before making your decision. "Paralyzing a muscle, even for four months — is that something they really want to do?" he asks. "People have to make a judgment call and they have to know there's toxin in the syringe. There's risk associated with this, and from the medical perspective there is no benefit."